How should I approach the management of a patient with IgA nephropathy who presents with hypertension and proteinuria?

Management of a patient with IgA nephropathy presenting with hypertension and proteinuria should focus on controlling blood pressure and reducing proteinuria to slow disease progression and protect kidney function. First-line pharmacological treatment involves initiating an angiotensin-converting enzyme (ACE) inhibitor or an angiotensin receptor blocker (ARB), titrated to the highest tolerated dose, as these agents reduce proteinuria and provide renal protection. This approach aligns with NICE recommendations for chronic kidney disease (CKD) patients with persistent proteinuria and hypertension, where an ACE inhibitor or ARB is offered if the albumin:creatinine ratio (ACR) is 70 mg/mmol or more, or considered with specialist advice if ACR is between 30-70 mg/mmol NICE CKS,NICE CKS,NICE NG203.

Blood pressure targets should be individualized based on proteinuria severity: for ACR under 70 mg/mmol, aim for a clinic systolic blood pressure below 140 mmHg and diastolic below 90 mmHg; for ACR 70 mg/mmol or more, a lower target of systolic below 130 mmHg and diastolic below 80 mmHg is recommended NICE NG203.

In addition to pharmacotherapy, lifestyle modifications such as dietary sodium reduction, weight management, and smoking cessation should be advised to support blood pressure control NICE NG136.

Referral to nephrology is indicated for patients with high levels of proteinuria (ACR ≥70 mg/mmol) or declining renal function to consider further interventions and monitoring NICE CKS,NICE CKS,NICE NG203.

Emerging evidence from the literature on IgA nephropathy supports the use of renin-angiotensin system blockade as the cornerstone of treatment to reduce proteinuria and slow progression Rosselli et al. 2011. Some studies also suggest that immunosuppressive therapy may be considered in selected patients with persistent proteinuria despite optimal supportive care, but this should be guided by specialist assessment Rosselli et al. 2011.

Overall, the management strategy integrates UK guideline recommendations for CKD with proteinuria and hypertension and the specific pathophysiology and treatment considerations of IgA nephropathy described in the literature.